Gingival crevicular fluid

 Introduction
 Transduate /Exudate
 Gingival vasculature and crevicular fluid
 Permeability of junctional and oral sulcular
epithelium
 Methods of collection

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gingival crevicular fluid 1
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 GCF fluid flow
 Composition of GCF
 Biochemical markers of the progression of
periodontitis
 Clinical significance
 Conclusion

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 The gingival sulcus
is the shallow crevice or
space around the tooth ,
bounded by the surface
of the tooth on one side and
the epithelial lining the
free margin of the
gingiva on the other.

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• It is V Shaped. The depth as
determined with histological sections
is 1.8mm.

• The so-called probing depth of a
clinically normal gingival sulcus is 2
to 3 mm

• Sections show presence of three
types of epithelium,
1. the oral or keratinized epithelium
covering the gingival connective
tissue in continuation with

2. the sulcular epithelium ,which is not
keratinized. It forms the soft tissue
wall of the gingival sulcus and the

3. junctional epithelium is in
continuation with the oral and
sulcular epithelium. It is formed by
few strata of cells, with long flat
basal layer and a very small
desquamating surface that forms the
base of the gingival sulcus.

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 Studies on gingival crevice fluid (GCF) extend over a period
of about 50 years

 The pioneer research of Waerhaug (1950) was focused on
----- the anatomy of the sulcus and its transformation into
a gingival pocket during the course of periodontitis.

 Studies by Brill et al. laid the foundation for understanding
the physiology of GCF formation and its composition.

 The studies of Löe et al. ----- use of GCF as an indicator of
periodontal diseases.

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 Egelberg continued to analyze GCF and focused his
studies on the dentogingival blood vessels and their
permeability as they relate to GCF flow.
 Attstrom R, Egelberg J. presence of leukocytes in gingival
crevice during developing gingivitis in dogs. JPR 1971 : 6; 110
-114.

 The GCF studies boomed in the 1970s. The rationale for
understanding dentogingival structure and physiology was
created by the outstanding electron microscopic studies of
Schroeder and Listgarten.

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 Presence and functions of proteins – Sueda, Bang and
Cimasoni.

 Collagenases and Elastase in GCF are derived from
human cells - Ohlsson, Golub, Uitto.

 Flow rate of GCF may increase about 30 times in
periodontitis patients than compared to healthy sites.

 Resting volume also increases with the formation of
pockets.

 Goodson thoroughly studied major issues in GCF flow
rate and its method of collection.

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 In 1974 the first edition of the monograph The Crevicular
Fluid by Cimasoni was published. This comprehensive
review gave a big boost to GCF studies and towards the
end of the first millennium the research on GCF increased
dramatically.

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Is GCF a Transduate of
interstitial fluid?
 From the work of Alfano (1974) and from the hypothesis
postulated by Pashley (1976) which suggested that the
initial fluid produced could simply represent interstitial fluid
which appears in the crevice as a result of an osmotic
gradient. This initial, pre-inflammatory fluid was considered
to be a transduate, and, on stimulation, this changed to
become an inflammatory exudate

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 The first studies by Alfano (1974) suggested that, at a
clinically healthy gingival crevice, bacterial plaque would result
in the accumulation of high molecular weight molecules.
These would permeate the intercellular regions of the
epithelium, but would then be limited by the basement
membrane.

 This hypothesis was supported experimentally, by the
application of phosphate-buffered saline containing 10 mg/ml
of homologous serum albumin which resulted in a 100%
increase in the volume of GCF produced. In contrast, the
application of phosphate-buffered saline alone did not
enhance the volume of GCF produced.

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 The model proposed by Pashley (Fig. 1)

predicted that GCF production is governed

by the passage of fluid from capillaries into

the tissues (capillary filtrate) and the removal

of this fluid by the lymphatic system

(lymphatic uptake). When the rate of

capillary filtrate exceeds that of lymphatic

uptake, fluid will accumulate as edema

and/or leave the area as GCF

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 Factors modulating:
 Filtration coefficient of the lymphatic and capillary
endothelium

 Osmotic pressure within the different compartments.

 Therefore, even in health also, if the osmotic pressure
of the sulcular fluid exceeds that of the tissue fluid,
(possibly because of accumulation of plaque derived
molecules) there will be net increase in the flow of
GCF.

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 Brill in 1959 demonstrated that increased vascular
permeability plays an important role in the production
of gingival fluid

 Egelberg in 1966, in a first experiment obtained an
increased permeability of the blood vessels of healthy
gingiva by the use of three different methods:
 topical application of histamine,
 gentle massage of the gingival by means of a ball-ended
amalgam plugger
 scraping of the gingiva crevice by means of a blunted
dental explorer

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 The capacity of the dentogingival vasculature to
respond with increased permeability and
phagocytosis following trauma was further
investigated by Soderholm and Attstrom in 1977
 Ranney and Montgomery in 1973 applied
Endotoxins to the gingival margin in dogs and
demonstrated an abnormal permeability of the
dentogingival vessels.
 Hellden and Lindhe in 1973 and Kahnberg et al in
1977 applied a plaque extract to the marginal gingiva
of dogs with healthy gingiva and also observed an
abnormal permeability of the dentogingival vessels as
well as increased flow of gingival fluid.

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 A fluid occurring in minute amounts in the gingival
crevice, believed by some authorities to be an
inflammatory exudate and by others to cleanse
material from the crevice, containing sticky plasma
proteins which improve adhesions of the epithelial
attachment, have antimicrobial properties, and exert
antibody activity. (From Jablonski, Illustrated
Dictionary of Dentistry, 1982

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 1) cleanse material from the sulcus

 2) contain plasma proteins that may improve
adhesion of the epithelium to the tooth.

 3) Possess antimicrobial properties.

 4) Exert antibody activity in defense of the gingiva.

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 Substances that have been shown to penetrate the
sulcular epithelium include albumin, Endotoxins,
thymidine, histamine, phenytoin, peroxidase.

 The main pathway for the transport of substances
across the junctional and sulcular epithelia seems to
be the intercellular spaces which according to
Schroeder and Munzel – Pedrazzoli (1970) form
18% of the total volume of the junctional epithelium
and 12% that of the oral sulcular epithelium.

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 According to Squier (1973) the degree of permeability of the oral
mucosa does not seem to depend upon its degree of Keratinization.
The mechanisms of penetration through an intact epithelium were
reviewed by Squier and Johnson.

 Three routes have been described:

 Passage Form CT Into The Sulcus:

 Passage From The Sulcus Into The CT:

 Passage Of Substances Through

Pathological Or Experimentally

Modified Gingival Sulcus:

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 In a series of experiments, Brill verified the
assumption that

Interstitial fluid entered the gingival sulcus
through its epithelial wall ------ by showing that
the tracer material, Sodium fluorescein administered
parenterally or per orally, could be recovered form the
gingival sulcus but not form other oral epithelia.

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 Numerous investigations have studied the
penetration of substances of varying molecular weight
most frequently by introducing labeled molecules in
the gingival sulcus of experimental animals and
studying their presence in the gingival CT by auto
radiography or in the general circulation by sampling
of venous blood.

 The passage of substances from the gingival sulcus
into the CT has been mostly studied in animals. Only
few observations have been performed in man.

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presence of plasma
 Brill was also first to show the
proteins in the gingival fluid.
 The fundamental observations of Brill have been confirmed
in other experiments, where it was shown that extraneous
materials such as India Ink, labeled albumin or labeled
fluorescein, tetracycline and saccharated iron oxide could
be seen to pass from the gingival vessels into the gingival
sulcus or pocket

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Intra
crevicular

Extra
crevicular

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Methods of collection of GCF

ABSORBING PAPER
INTRACREVICULAR
WASHINGS STRIPS

METHOD OF
COLLECTION

TWISTED
MICROPIPETTES THREADS

These strips are placed within the
sulcus (Intrasulcular method) or at its
entrance (Extrasulcular method). The
placement of filter paper strip in
relation to the sulcus or pocket is
important.
The Brill technique places it
into the pocket until resistance is
encountered.
DISADVANTAGE ---- This method
introduces a degree of irritation of the
sulcular epithelium than can, by itself
trigger the oozing of fluid.

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 To minimize this irritation, Loe and Holm –
Pedersen placed the filter paper strip just at the
entrance of the pocket or over the pocket entrance. In
this way, fluid seeping out is picked up by the strip,
but the sulcular epithelium will not be in contact
with the paper.

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Threads were placed in the gingival crevice around the
tooth ,and the amount of fluid collected was
estimated by weigh in the sample thread.

Used by WEINSTEIN et al

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KRASSE AND EGELBERG were first to utilize capillary
tubing.
This permits the collection of fluid by capillary action.
After isolation and drying of collection site, capillary tubes
of known diameter are inserted into the entrance of
gingival crevice, GCF migrates into the tube by capillary
action.
As diameter is known, the amount of GCF can be
calculated by measuring the distance which the GCF
has migrated.
And finally, their content is then centrifuged and analyzed.

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 Disadvantages:
 Long collection period

 May cause trauma as excessive holding of pipette is
required

 The collection of the fluid is difficult because the
viscosity of the fluid makes the aspiration difficult

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 The Method Of Oppenheim:
This method uses an appliance consisting of a hard
acrylic plate covering the maxilla with soft borders
and a groove following the gingival margins,
connected to four collection tubes.
 The washings are obtained by rinsing the
crevicular areas from one side to the other, using a
peristaltic pump.

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 ADVANTAGES:
 Useful for longitudinal studies

 Permits collection without disturbing the integrity of the
marginal tissues

 Contamination is least

 DISADVANTAGES:

 Complex procedure

 Represents a dilution of crevicular fluid

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 The Method Of Skapski And Lehner:

 This method uses two injection needles fitted one within
the other such that during sampling the inside, or
ejection, needle is at the bottom of the pocket and the
outside, or collecting, one is at the gingival margin. The
collection needle is drained into a sample tube by
continuous suction

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 ADVANTAGES
 Useful for cases of clinically normal gingival

 Useful for studying the number and state of cells and
bacteria form the crevicular area

 DISADVANTAGES;

 Does not permit absolute Quantitative assessment as
the dilution factor cannot be determined

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 Contamination

The major sources of contamination of GCF sample would be
blood, saliva, or plaque.

 Sampling time

The problem with prolonged collection times is that the nature
of the GCF sample collected is likely to change with the
protein concentration of the initial GCF collected.

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 Volume determination

 Recovery from strips

 Data reporting

Constituents found within GCF samples have either

been reported as absolute amount (mg), concentrations

(mg/ml)

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 Simple linear measurement:
 Amount of GCF collected on strip was assessed by the
distance the fluid had migrated up the strip.

 A more accurate value was achieved by
 assessing the area of filter paper wetted by GCF sample.

 Staining method: the strip is stained with ninhydrin to
produce purple color in the area where GCF had
accumulated.

 Also 2g fluoroscein given systemically to each patient 3hrs
prior to the collection following which the strips were
examined under UV light.

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 Disadvantages of staining method:
 Cannot be used chair side.

 Inevitable delay in measurement may result in increase
variation due to evaporation of the fluid.

 Staining of the strips for protein labeling prevents
further lab investigations.

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 Challacombe used an isotope dilution method to
measure the amount of GCF present in a particular
space at any given time.

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An electronic method has been devised for measuring gingival fluid absorbed on
paper strips by Harco electronics called Periotron (Dental product division
Winnipeg, Manitoba, Canada).

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 An electronic measuring device which measures the affect on
the electric current flow of wetted paper strip.

 It has 2 metal jaws which acts as the plates of an electrical
condenser.

 When a dry strip is places  zero reading is obtained

 A wet paper strip will increase the capacitance in proportion to
the volume of fluid and this can be measured as an increased
value in the readout.

 Three models  600, 6000 and 8000.

 Limitations: inability to measure the volume of FCG greater
than 1.0µl.

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Composition of GCF

ENZYMATIC COMPONENTS NON ENZYMATIC COMPONENTS

HOST DERIVED BACTERIA DERIVED
HOST
DERIVED
AND
AND OTHER
OTHER
PRODUCTS
PRODUCTS CELLULAR ELECTROLYTES ORGANIC
COMPONENT COMPONENTS

Acid phosphates
Alkaline phosphatase
Alpha 1 antitrypsin
Arylsulphatse
Aspartate aminotransfarase
Chondroition sulphate
Citric acid
Cystatins
B-glucuronidase
Cathepsin
Matrix metalloproteins
Elastase

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 Acid phosphatase

 Alkaline phosphatase

 Collagenase

 Hyaluronidase

 Phospholipse-A

 Phospholipase-C

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Cellular elements
Bacteria
Desquamated epithelial cells
Leucocytes ( PMN’S, monocytes/macrophages)
Electrolytes
Potassium
Calcium
Sodium
Organic compounds
Carbohydrates-GLUCOSEHEXOSAMINE
-HEXURONIC ACID
Proteins

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 Lactic acid

 Urea

 Hydroxyproline

 Endotoxins

 Cytotoxic substances

 Hydrogen sulphide

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 The cellular elements found in the gingival fluid
include bacteria, desquamated epithelial cells, and
leukocytes (PMN’s, lymphocytes and monocytes)
which migrate through the sulcular epithelium.

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Potassium, sodium, calcium,
magnesium and fluoride have been
studied in gingival fluid. Most studies
have shown a positive correlation of
calcium and sodium concentrations
and the sodium to potassium ratio
with inflammation.

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 The first quantitative study on the absolute conc.
of sodium and potassium in gingival fluid has been
preformed by Matsue (1967).

 The mean conc. of sodium found in GCF was 174.
and serum conc. of same point was found to be 136
(±7.9) significantly lower than that of GCF (Baug
et al 1973)

 So sodium concentration is more in GCF than
serum and it increases in cases of severe
inflammation

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 The potassium content of GCF is also generally more
than that of serum. Values as high as 69 mEg/lit. have
been reported by Nature (1967) from the inflamed areas.

 The potassium content of crevicular exudate tended to
increase in cases showing more severe periodontitis.

 As suggested by Rasse & Egelberg (1962) the fluid passes
through damaged tissues a decrease sodium : Potassium
ratio would be found because of the accumulation of
intracellular potassium from the disrupt cells.

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 Carbohydrates, proteins and lipids have been
investigated. Glucose hexosamine and hexuronic acid
are two of the compounds found in gingival fluid.
Glucose concentration in gingival fluid is 3-4 times
greater than that in serum.

 This is interpreted not only as a result of metabolic
activity of adjacent tissues, but also as a function of
the local microbial flora.

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 The total protein content of gingival fluid is much less
than that of serum. No significant correlations have
been found between the concentration of proteins in
the gingival fluid and the severity of gingivitis, pocket
depth and extent of bone loss.
 Proteins namely , , 2 and 1 globulins, transferrin,
albumin, immunoglobulins such as IgG, IgM and IgA,
complement components such as C1, C4, C3, C5, have
been reported to be present in GCF.
 Proteins Include: - fibrinogen, ceruloplasmin, -
lipoprotein, transferrin, 1 – antitrypsin and 2 –
macroglobulin.

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Metabolic and bacterial products
identified in gingival fluid include
lactic acid, urea, hydroxy
proline, endotoxins, prostaglandins, c
ytotoxic substances, hydrogen
sulphide and antibacterial factors.

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Various enzymes known to be present in gingival
fluid include: -
 Acid phosphatase,
 Alkaline phosphatase,
 Pyrophosphatase,
 - Glucoronidase,
 Lysozyme,
 Hyaluronidase,

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Proteolytic enzymes includes:
 Cathepsin D,

 Elastase,

 Cathepsin G,

 Plasminogen activators,

 Collagenase and

 Bacterial proteinases (i.e. endo and exopeptidases), and

 Lactic dehydrogenase serum proteinase inhibitors such as 2 –
macroglobulin, 1 – antitrypsin, 1 – antichymotrypsin have
also been known to be present in GCF.

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 According to Armitage (2004), more than 65 GCF
constituents have been evaluated as potential
diagnostic markers of periodontal disease
progression.

 PGE2 was first identified in GCF by Goodson et al. in
1974.

 PGE2 is a product of the cyclooxygenase pathway.
Elevated levels of PGE2 in GCF were found in patients
with periodontitis compared to patients with
gingivitis. PGE2 levels were three times higher in
patients with juvenile periodontitis compared to adult
periodontitis.

 Offenbacher et al (1986) showed that there were
differences in the GCF concentration of PGE2 in
patients with gingivitis compared with periodontitis.
Subsequently, it was found that there was a
correlation between increased PGE2 concentration
and clinical attachment loss in patients who were
diagnosed with moderate to severe periodontitis.

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 Cytokines are potent local mediators of inflammation that are
produced by variety of cells. Cytokines that are present in GCF
and have been investigated as potential diagnostic makers for
periodontal disease include:
 interleukin - 1 , 1 ,

 interleukin – 6,

 interleukin – 8 and

 tumor necrosis factor (TNF - ).

 Both IL - 1 and IL - 1 have pro-inflammatory effects and
depending on a variety of factors can stimulate either bone
resorption or formation.

 It has also been reported that in adult periodontitis
patients, a higher percentage of sites are positive for IL - 1
(87%) and IL - 1 (56%) IL-6 has also been associated with
bone resorption. GCF from sites with progressing
periodontitis contains elevated amounts of IL-6.

 IL-8 was formerly called monocyte-derived neutrophil
chemotactic factor. GCF from sites with periodontitis
contains significantly more total IL-8 than GCF from
healthy sites

 Proinflammatory cytokines in particular IL-1•, may
play an integral role in the aetiology of periodontal
disease.

 Lieu et al (1996) demonstrated that with an increase in
gingival index and probing, there was a corresponding
increase in IL-1 in both the gingival tissue and GCF.

 Engebretson et al through a longitudinal study
suggested that GCF IL-1• expression is genetically
influenced and not solely a result of local clinical
parameters. Also, a GCF level of IL8 was found to be
higher in periodontal diseases and was influenced by
local IL-1 activities.

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 Several reports suggest that, compared to periodontal
healthy controls, GCF from sites with periodontitis
has significantly elevated levels of total protein.

 Some study has reported that GCF from inflamed
sites in patients with periodontitis have significantly
lower protein concentrations than GCF from inflamed
sites in patients with gingivitis alone

(a) Aspartate Aminotransferase:

 Aspartate aminotransferase enzyme (AST) is one of
the components of GCF that is released and can be
detected as a result of cell death.

 Significant associations between GCF levels of AST
and clinical measurements have been determined,
and a test system, the PeriogardTM periodontal tissue
monitors (PTM), has been developed (Persson et al
1990.

 The commercial chair side test do not have the
ability to reliably distinguish between progressing
sites and those that are inflamed but not progressing.

 Alkaline phosphatase is a glycoprotein and membrane
bound enzyme. It hydrolyzes monophosphate ester
bonds at alkaline pH, increasing local concentrations of
phosphate ions.

 In the periodontium, alkaline phosphatase is a very
important enzyme as it is part of the normal turnover of
periodontal ligament, root cement formation and
maintenance, and bone homeostasis.

 It is produced by many cells, including fibroblasts,
osteoblasts and osteoclasts, but the main source of
alkaline phosphatase in gingival crevice fluid is
neutrophils.

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 Similar levels of alkaline phosphatase in GCF have been
found in gingival health and experimental gingivitis, but
a longitudinal study demonstrated that elevated alkaline
phosphatase levels preceded clinical attachment loss
and that the total amount of alkaline phosphatase in
GCF was significantly higher in active sites (Nakashima
1996).

 The diagnostic value for alkaline phosphatase was
limited; while the specificity for alkaline phosphatase as
diagnostic marker was 86%, it appeared to have a 30%
sensitivity.

 Beta-glucuronidase is a lysosomal enzyme that is
active in the hydrolysis of glycosyl bonds of
intercellular ground substance. It is highly
conceivable, therefore, that periodontal disease
activity is associated with increased levels of beta-
glucuronidase in gingival crevice fluid

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 ß glucuronidase is a glycoprotein of about 332,000 dalton.
It is a homo tetramer comprised of four identical subunits.
It has high sensitivity and specificity when related to
occurrence of clinical attachment loss. This enzyme also
proved to be a good predictor of the response to treatment
and the risk for future periodontal breakdown (Lamster et
al 1998).

 Subjects without active disease did not have elevated beta-
glucuronidase in gingival crevice fluid. In relation to
attachment loss, they observed beta-glucuronidase to have
a sensitivity and specificity of 89% and 89%, respectively.

 Neutrophil elastase, sometimes referred to as
granulocyte elastase, is an abundant proteinase
released from the azurophilic granules of neutrophils,
and as such is an indicator of neutrophil activity.

 Neutrophil elastase is a serine proteinase, active in
the degradation of microbiological components in
conjunction with, or without, phagocytosis. At the
same time, when released extracellularly, this enzyme
can degrade host intercellular matrix components,
including elastin, fibronectin, and collagen.

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 Elastase levels in GCF increase with induction of experimental
gingivitis, and decrease when plaque removal is reinstituted.

 In a longitudinal study, Eley and Cox (1996) demonstrated
that increased elastase in GCF was predictive of periodontal
attachment loss. Long-term observation of adult patients with
periodontitis undergoing supportive periodontal therapy
showed a positive correlation of elastase in GCF with clinical
attachment loss.

 Smokers display higher levels of elastase than nonsmokers.
 Soder B, Jin LJ, Wickholm S. Granulocyte elastase, matrix
metalloproteinase-8 and prostaglandin E2 in gingival crevicular fluid
in matched clinical sites in smokers and non-smokers with persistent
periodontitis. J Clin Periodontol 2002: 29: 384–391

 Cathepsin B is an enzyme active in proteolysis; it
belongs to the class of cysteine proteinases. The
cellular source of cathepsin B in gingival crevice fluid
seems to be mainly macrophages.

 Cathepsin B activity has been found in gingival
crevice fluid in adult periodontitis. It seems to be
increased in periodontitis but is not increased in
gingivitis, even though the flow of gingival crevice
fluid is more or less equal in these two periodontal
conditions.

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 Kunimatsu et al (1990) observed that levels of cathepsin B
were increased in periodontitis when compared to
gingivitis, despite similar GCF flow.

 Furthermore, GCF levels of cathepsin correlate
significantly with clinical parameter before and after
periodontal treatment suggesting a use for this enzyme in
assessment of treatment outcomes. Cathepsin G may
contribute to periodontal tissue destruction directly and
indirectly, via proteolytic activation of latent neutrophil
procollagenase (promatrix metalloproteinase-8).

 Eley & Cox have further investigated cathepsin B and
evaluated its use as a predictor of attachment loss.

(g) Collagenases / Gelatinases / Neutral proteinases
Stromelysins:

 GCF from sites with adult or juvenile forms of periodontitis
exhibit significantly elevated collagenolytic activities
compared to GCF from healthy or gingivitis sites.

 In ligature-induced periodontitis in the beagle dog, GCF
collagenase activity increased to maximum values within
weeks after ligature placement, active collagenase was
elevated during active periodontitis and active collagenase
was strongly correlated with attachment loss. Latent
collagenase and collagenase inhibitors were prominent
during gingivitis.

(a) Glycosaminoglycans (GAG’s):

 The GAG’s in GCF that have been most examined
as possible diagnostic markers for periodontal diseases
are:
 Chondroitin – 4 – sulfate,

 chondroitin – 6 – sulfate and

 hyaluronic acid.

 The appearance of C-4-S in GCF has been
suggested as a marker for bone resorption associated
with periodontal disease or orthodontic tooth movement.
But no studies have been conducted to determine its
role in the progression of periodontitis.

(b) Hydroxyproline:

 It is a prominent aminoacid of collagen and its
appearance in GCF has been preliminary investigated as a
marker for the destruction of periodontal connective tissue.
Data from one cross-sectional study in humans indicate
that GCF hydroxy proline levels cannot distinguish between
sites with gingivitis or periodontitis. Because of this it is
not an attractive candidate as a potential marker for the
progression of periodontitis.

(c) Fibronectin:

 These are a large group of heterogeneous glycoprotein
present in blood and connective tissues. Data from most
studies indicate that GCF fibronectin is not a promising
diagnostic marker.

(d) Connective Tissue Proteins:

 Increased GCF levels of the amino terminal propertied
of type I collagen have been reported at periodontitis sites.
On a concentration basis, the amount of osteocalcin in
GCF does not appear to be different at sites with gingivitis
or periodontitis.
 Osteonectin another non-collagenous protein of bone
and a variety of other tissues, has been reported to be
elevated in GCF at sites with severe periodontitis. Neither
Osteocalcin nor Osteonectin levels in GCF have been
systematically evaluated as diagnostic markers for
periodontitis.

It is evident that since periodontal disease is
associated mainly with the presence of certain
bacteria which are recognized as the principal
etiological agents, then factors derived from such
bacteria may be useful indicators of their presence
and metabolic activity.

Lipopolysaccharides (Endotoxins)

These molecules are found in the outer membrane of the cell
wall of Gram-negative bacteria. The presence of endotoxins
has been positively correlated with gingival inflammation
(Simonet al, 1971) when measured in GCF and in
combination with clinical and histological studies. The level
of endotoxin is related to the number of Gram-negative
bacteria.

Lipopolysaccharides (LPS) vary in their structure depending
on bacterial source.

Bacterial Enzymes

 Perhaps the bulk of the work on bacterial enzymes
has been carried out on proteolytic enzymes or
proteinases.

 The most studied would be the trypsin-like proteinase
of P.gingivalis.

 Similar trypsin-like enzymes are also associated with
Treponema denticola (Makinin et al, 1987).

 Bacterial collagenases are also identified with Clostridium
histolyticum and Streptococcus mutans.

 The presence of such enzymes in GCF correlates with the
levels of these bacteria in the periodontal pocket and also
with the severity of the attachment loss.

Lactoferrin

This is an antimicrobial agent with a distribution in PMNs and

secretory fluids similar to that of Lysozyme. The antibacterial

properties of Lactoferrin are due to its high affinity for iron, thus

locking available sources required for bacterial growth.

Lactoferrin showed better correlation with clinical indices

than PMNs (Adonogianaki et al, 1993).

Friedman et al (1983) found that Lactoferrin increased
twofold in GCF in sites showing gingivitis
periodontitis, and localized juvenile periodontitis. It
has also been reported that the ratio of Lactoferrin to
Lysozyme may be more representative and a useful
diagnostic assay of periodontal inflammation.

Myeloperoxidase

This enzyme has also been shown to give good correlation
with an inflammatory response where it is found in the
primary granules of PMN (Smith et al, 1986).

 Several products show potential benefit, particularly
those directly from specific regions of the
periodontium which give a clue as to which tissue
components are at risk. It is clear that no single
marker will fulfill all the criteria necessary for
assessment of the clinical state of the periodontium,
and future research should be directed at the
production of "marker packages". The development of
a wide spectrum of marker factors will be a primary
goal of periodontal research.

 COMMERCIALY AVAILABLE DIAGNOSTIC KIT
 Periocheck - Neutral Proteinases - Approved by FDA

 Periogard - AST

 Prognostik- Elastase - Not Approved by FDA and ADA

 Biolise - Elastase

 Pocket watch - AST

 TOPAS – Toxicity Pre-screening assay (bacterial toxins and proteases

 MMP dipstick method - MMPs

 Under development, for B - glucornidase and proteinases

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 The components of gingival crevice fluid are analyzed
with regard to their potential utility in fulfilling the
following aims: (BRUNO G. LOOS & STANLEY TJOA)
 AIM 1 To detect a case of periodontitis, i.e., to
distinguish periodontitis from health and gingivitis
 AIM 2 To classify a case of periodontitis, i.e., chronic
periodontitis or aggressive periodontitis
 AIM 3 To plan treatment for the patient on the basis of
the level of disease activity
 AIM 4 To monitor the treated patient based on the level
of disease activity

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 Circadian Periodicity:

There is a gradual increase in gingival fluid amount
from 6:00AM to 10:00PM and a decrease afterward.

On the other hand in the studies conducted by a
group of investigators, there are no systematic
differences between the flow of fluid measured at
9:00a.m and that of the fluid collected at 3p.m

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 GCF and sex hormones
Clinical investigations have shown an exacerbation of
gingivitis during pregnancy (loe 1965) during the
menstrual cycle (------Lemann 1948) and at puberty
(Sutcliffe 1972). Female sex hormones increase the
gingival fluid flow, probably because they enhance
vascular permeability.

Pregnancy, ovulation and hormonal contraceptives all
increase gingival fluid production.

2012

 During menstrual cycle gingival fluid flow or exudate
values are significantly higher on the day of ovulation
as compared to those obtained during the menstrual
days. ( Lindhe and Attstrom (1967).

 Lindhe and Brorn (1967) reported a 53% increase of
GCF flow in the women using birth control pills as
compared to the control subjects.

 Hugoson (1970) reported that the gingival exudate,
reached maximum values during the last trimester
and decreased to minimum 20 wks after delivery.

2012

 GCF and drugs

Drugs that are excreted through the gingival fluid
may be used advantageously in periodontal therapy.
Bader and Goldhaber were able to show that
intravenously administered tetracycline in dogs
rapidly emerges within the sulcus.

2012

 Ciancio et al (1976) measured the concentration of
tetracycline in blood and gingival fluid of 5 adult
patients with advanced periodontitis, who were given
1g of tetracycline HCL daily for 2 weeks and 0.5g for
10 weeks. The concentration of the drug in gingival
fluid was 1/10 of that found in serum.

 In a second study from the same laboratory the
concentrations of the drug were found to be 5 times
higher in samples of gingival fluid as compared to the
concentrations in blood.

2012

 Stephen et al (1980) measured the cone. of
ampicillin, cephalexin, tetracycline erythemycin,
clindamycin and rifampicin in serum, saliva and GCF
after a single and dose administration Except on one
occasion, individual GCF antibiotic conc. were equal
to or considerably greater than those found in saliva.
But they were, however, always much lower than the
concentration found in serum.

 Metronidazole is another antibiotic that has been
detected in human GCF. (Eiserbeng et-al 1991).

2012

 GCF in diabetic patients

Ringelberg et al in 1977 described a higher flow rate
of gingival fluid in a group of diabetic children, when
compared to the flow rate measured in a group of
children without diabetes.

In healthy individuals Hara and Löe found exudate
glucose values up to 6 times those of serum. Kjellman
(1970) reported glucose values much lower in gingival
fluid when compared to serum, this being true for
both healthy and diabetic patients.

2012

 Periodontal therapy and GCF
There is an increase in gingival fluid production during
the healing period after periodontal surgery. According
to Arnold et al 1966 this increase was probably the
result of the inflammatory reaction from gingival trauma
and the loss of an intact epithelial barrier, especially
considering the fact that fluid had been collected by
deep intracrevicular technique.
Suppipat et al in 1978 sampled gingival fluid 14, 21, 28
and 35 days after gingivectomy and found an increase in
gingival fluid flow during the first 2 weeks after surgery
followed by a gradual decrease. This decrease was same
when using mechanical or chemical plaque control

2012

 Arnold et-al (1968) observed that 1 week after
gingivectomy there was a striking increase in gingival
fluid flow. This was probably the result of the
inflammatory reaction from gingival trauma and of
the loss of an intact epithelial barrier. With the
restoration of gingival integrity, a gradual drop in
fluid flow occurred and the flow rate reached a
minimal value 5 wks after gingivetomy.



2012

 Influence of mechanical stimulation

Chewing and vigorous gingival brushing stimulate the
oozing of gingival fluid. Even the minor stimuli
represented by Intrasulcular placement of paper
strips increase the production of fluid.

2012

 Smoking and GCF
Smoking produces as immediate transient but marked
increase in the gingival fluid flow.

Mcluaghlin WS et al 1993

2012

 In conclusion one can say that the origin, the
composition and the clinical significance of gingival
fluid are now known with more precision and have
significantly helped our understanding of the
pathogenesis of periodontal disease. Up to now, for
instance, none of the multiple components analyzed
in the fluid has improved clinical judgment of the rate
of progress of gingivitis and periodontitis or of the
rate of repair of these conditions.

 CARANZZA

 Griffiths. Formation, collection and significance of
GCF. Periodontal 2000 ; 2003 : volume 31, 32 – 42.

 Andrew J. Delina. Origin and function of the cellular
components in GCF. Periodontal 2000; 2003: vol. 31,
55 – 76.

 J. Max Goodson. Gingival crevicular fluid. Periodontal
2000; 2003: vol.31, 43 – 54.

2012

 Ira B. Lamster. Evaluation of Components of Gingival
Crevicular Fluid as Diagnostic Tests. Annals of
periodontology. Vol. 2, No. 1, March 1997

 BRUNO G. LOOS & STANLEY TJOA. Host-derived
diagnostic markers for periodontitis: do they exist in
gingival crevice fluid? Periodontology 2000, Vol. 39,
2005, 53–72

2012

Gingival crevicular fluid

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